In order to file a Boston Mutual Claim Bd 1321 0706 Form, you will need to gather some important information. The first step is to make sure that you have the correct form. You can find the form on the Boston Mutual website, or you can contact their customer service department for a copy. Once you have the form, you will need to fill it out completely and accurately. Be sure to include all of your contact information, as well as the details of your claim. Submit the form and supporting documentation to Boston Mutual, and they will take care of the rest.
If you wish to first find out how much time you will need to fill in the boston mutual claim bd 1321 0706 form and how many pages it has, here is some general information that will be of use.
Question | Answer |
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Form Name | Boston Mutual Claim Bd 1321 0706 Form |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | utual savings form, boston mutual claim, boston mutual life insurance log in, boston mutual life insurance company claims |
Boston Mutual Life Insurance Company
Group Disability
Claim Filing Instructions
IMPORTANT: All portions of this claim form must be completed after disability begins to avoid undue delay in processing claimant’s request for benefits. If you have any questions when completing this form, please call our:
Toll Free Number - (800)
1.Complete "Employee - Initial Disability Benefits Claim Form" in full.
2.Have treating physician complete the "Physician - Initial Disability Claim Form" and return to you.
3.Have Employer complete the "Employer - Initial Claim Form" and return to you.
4.Submit all completed forms to the address below or you may fax all completed forms to our:
Toll Free Fax Number - (888)
Mail To:
Boston Mutual Life Insurance Company
Benefits Administration
P.O. Box 268956
Oklahoma City, OK
Mail to: Boston Mutual Life Insurance Company
Benefits Administration
P.O. Box 268956
Oklahoma City, OK
Toll Free Phone #
Toll Free Fax #
EMPLOYER – INITIAL CLAIM FORM
Employee Name:
Occupation:
Social Security Number:
Hire Date:
STATUS OF EMPLOYMENT: Full Time: ❏ |
Part Time: ❏ |
Days per week: ________ Hours per day: _________ |
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If employee’s status has changed, please check the appropriate box and provide change date below: |
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Lay Off: ❏ |
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Leave of Absence: ❏ |
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Terminated: ❏ |
Retired: ❏ |
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PREMIUMS: |
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Are the employee’s disability premium contributions deducted |
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What percentage of the disability premiums do you pay?_________% |
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Are Social Security taxes withheld from employee’s pay check? Yes ❏ No ❏ |
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Date that last disability premiums deducted from payroll:___________ Amount deducted: $__________ |
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SALARY AT TIME OF DISABILITY: |
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Hourly: $_________ |
Weekly: $__________ Monthly: $__________ |
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Annually: $__________________ |
$_____________________ |
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Date last worked?______________________ |
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Has employee returned to work? Yes ❏ No ❏ Return date: ________________ Full Time ❏ Part Time ❏ |
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Is the employee receiving or eligible to receive any of the following? |
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Dates Benefits |
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Yes |
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Amount |
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Company Name and Phone Number |
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Begin |
End |
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Other Group |
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Disability |
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$ |
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Salary |
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Continuation |
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$ |
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Sick Leave |
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❏ |
❏ |
$ |
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PTO/PPT |
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$ |
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Other (Bonus, etc.) |
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$ |
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Retirement/Pension |
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❏ |
❏ |
$ |
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❏ |
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Is disability the result of work related injury/illness? Yes ❏ No ❏ |
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If yes, has a Workers' Compensation claim been filed? Yes ❏ No ❏ |
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Please provide name and phone number of Workers' Compensation carrier: |
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Employer Name: |
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Office Phone Number: |
Fax Phone Number: |
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Street Address: |
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City: |
State: |
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Zip Code: |
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Form completed by: (please print) |
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Title: |
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Signature: |
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Date: |
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This documents that the above statements are true and complete to the best of my knowledge. |
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Mail to: Boston Mutual Life Insurance Company
Benefits Administration
P.O. Box 268956
Oklahoma City, OK
Toll Free Phone #
Toll Free Fax #
EMPLOYEE - INITIAL DISABILITY CLAIM FORM
WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud and subject to criminal and civil penalties.
Name:
Social Security Number: |
Date of Birth: |
Complete Mailing Address:
Complete Resident Address:
Telephone Number:
Do you have dependents under age 18? Yes ❏ No ❏ If yes, please list dependent names and birth dates below:
1)Please list medical condition or injury causing disability:
2)If disability is the result of an accident, please explain where, when, and how accident happened:
3)Is your disability the result of your employment? Yes ❏ No ❏ If yes, please submit copy of Workers' Compensation award or denial letter.
4)Please list all dates of medical treatment pertaining to current disability:
5)Have you ever had or been treated for same or
similar condition? Yes ❏ No ❏ If yes, please explain:
6)Please list name and phone number of treating physician(s):
7)Date Last Worked:
Date Returned to Work:
8)If you have not returned to work, what is the anticipated return date?
❏Full Time: ______________________
❏Part Time:______________________
9)If your request for benefits is approved, do you want Federal Taxes withheld from each benefit check? Yes ❏ No ❏
If yes, please indicate dollar amount below:
(Minimum amount required is $87 per month.) $_______________
10) Please identify other income sources and amounts of income which you are receiving or may be entitled to receive during this disability:
Social Security - Disability ❏ Retirement ❏ |
Yes ❏ |
No ❏ |
$__________ |
V.A. Benefits |
Yes ❏ |
No ❏ |
$___________ |
Dependent Social Security |
Yes ❏ |
No ❏ |
$__________ |
Sick Leave or Wage Continuation |
Yes ❏ |
No ❏ |
$___________ |
State Disability |
Yes ❏ |
No ❏ |
$__________ |
Retirement (normal, early, or disability) |
Yes ❏ |
No ❏ |
$___________ |
Other Group Disability Coverage |
Yes ❏ |
No ❏ |
$__________ |
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Include a copy of your award or denial letter from any source that you have received.
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
I hereby authorize the entities specified below to disclose any information about my entire medical record and history of treatment for physical and/or emotional illness
to include psychological testing, except psychotherapy notes, to individuals representing Boston Mutual Life Insurance Company (BMLIC) who are involved in determining whether I am eligible for benefits under my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals, clinics or
NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) or other conditions for which you may have been treated. This authorization excludes disclosure of the result of a test for HIV if you have tested HIV positive but have not developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in the caveat will prohibit this authorization from including the fact that you have AIDS.
I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the authorization may result in a denial of benefits. I understand that I may revoke this authorization at any time by writing to Boston Mutual Life Insurance Company, Benefits Administration, P.O. Box 268956, Oklahoma City, Oklahoma
For health insurance coverage, this authorization will expire
Signature :____________________________________________ Print Insured’s/Patient Name: ______________________________________ Date:_______________
Please retain a copy for your personal records, or you may request a copy from our company.
FAILURE TO SIGN & DATE FORM WILL DELAY BENEFITS |
Mail to: Boston Mutual Life Insurance Company
Benefits Administration
P.O. Box 268956
Oklahoma City, OK
Toll Free Phone #
Toll Free Fax #
PHYSICIAN - INITIAL DISABILITY CLAIM FORM
Patient’s Name:
Social Security Number: |
Date of Birth: |
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Diagnosis: Please list diagnosis resulting in patient’s temporary total disability (including complications) |
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Diagnosis: ________________________________________________________________ |
ICD9 Code: __________________________________ |
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Diagnosis: ________________________________________________________________ |
ICD9 Code: __________________________________ |
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Is disability the direct result of patient’s employment? |
Yes ❏ No ❏ |
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Is disability the result of a pregnancy? Yes |
❏ No ❏ |
If yes, date pregnancy was diagnosed: |
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Delivery date: (if delivered) |
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Expected delivery date: (if not delivered) |
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History: Was the patient referred to you? |
Yes ❏ No ❏ Unknown ❏ If yes, please provide name and phone number of referring physician: |
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Date symptoms first appeared or accident happened? |
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Date patient first consulted you for this condition? |
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Are you aware if this patient has ever had the same or similar condition? Yes ❏ No ❏ If yes, please provide explanation including first date of onset.
Treatment: Is patient still under your care? Yes ❏ No ❏ If yes, date of next appointment: _____________________________________________
List all treatment dates:______________________________________________________________________________________________________
Please describe treatment plan: _______________________________________________________________________________________________
If patient is no longer under your care, please provide name and phone number of current physician: |
Unknown ❏ |
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Has patient been confined to a hospital? Yes ❏ No |
❏ Admitted: ___________________________ |
Discharged: _____________________________ |
Hospital Name: |
Phone Number: |
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If surgery is/was necessary, please list procedure(s): |
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Date scheduled: |
Date performed: |
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Prognosis: Please list date(s) of temporary total disability (unable to work) From: ________________ Through: __________________
If patient is currently totally disabled, please indicate the anticipated length of disability by checking the appropriate box below:
Months: ❏ |
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❏ or Permanently Disabled ❏ or Other |
❏ ________________________ |
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Impairment: List functional limitations/restrictions that render your patient temporarily totally disabled: |
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Attending Physician’s Name: (please print) |
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Degree: |
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Specialty: |
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Street Address: |
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City: |
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State/Zip Code: |
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Office Phone Number: |
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Fax Phone Number: |
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Federal Tax ID Number: |
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Form completed by:
Title:
Signature of Physician: |
Date: |
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Attention Physician: This form documents your verification that the above named individual is totally disabled from their occupation. You will be asked periodically for updates related to the individual’s disability and treatment plan.